I. California employers who are
required to record work-related injuries and illnesses on the Cal/OSHA Form 300
may use an equivalent form that includes all of the following instructions and
information.

Log of Work-Related Injuries and Illnesses

Instruction: You must record information about every work-related death and
about every work-related injury or illness that involves loss of consciousness,
restricted work activity or job transfer, days away from work, or medical
treatment beyond first aid. You must also record significant work-related
injuries and illnesses that are diagnosed by a physician or licensed health care
professional. You must also record work-related injuries and illnesses that meet
any of the specific recording criteria listed in 8 CCR 14300.8 through 14300.12.
Feel free to use two lines for a single case if you need to. You must complete
an Injury and Illness Incident Report (Cal/OSHA Form 301) or equivalent form for
each injury or illness recorded on this form. If you're not sure whether a case
is recordable, contact the nearest office of the Division of Occupational Safety
and Health for assistance.

Establishment Name & Address

Identify the Person (A)-(C)

A. Case Number

B. Employee's Name

C. Job Title

Describe the Case (D)-(F):

D. Date of Injury or illness

E. Where the event occurred

F. Describe the injury or illness, part(s) of the body affected, and
object/substance that directly injured or made the person ill

Classify the Case (G)-(M)

Using these four categories (G)-(J), indicate only the most serious result
for each case:

G. "Death"

H. "Days away from work"

I. Remained at work as "Other recordable cases"

J. Remained at work with "Job transfer or restriction"

Enter the number of days the injured or ill worker was:

K. Number of days the injured or ill worker was "On job transfer or
restrictions"

L. Number of days the injured or ill worker was "Away from work"

M. Indicate an injury or, one type of illness:

(1) Injury column

(2) Skin disorder column

(3) Respiratory condition column

(4) Poisoning column

(5) All other illnesses column

Page Totals {for columns (G)-(M)}

Instruction: Transfer these totals to the Summary page (Cal/OSHA Form 300A)
before you post it.

Instructions for privacy concerns:

"ATTENTION: This form contains information relating to employee health
and must be used in a manner that protects the confidentiality of employees to
the extent possible while the information is being used for occupational safety
and health purposes."